Norovirus Outbreaks in Nursing Homes Associated With Increase in Hospitalizations, Risk of Death

Norovirus Associated With Substantial Increased Risk Of Hospitalizations And Deaths Among Nursing Home Residents

Norovirus Associated With Substantial Increased Risk Of Hospitalizations And Deaths Among Nursing Home Residents

INTRO:Throughout the year but especially during the winter months outbreaks of norovirusÂ Â commonly referred to as the â€œstomach fluâ€ can occur. Symptoms may include abdominal cramps, vomiting and diarrhea. Outbreaks often occur in closed and crowded environments like nursing homes. A new study examined whether norovirus outbreaks were associated with increased risk of hospitalizations and death among nursing homes residents. Catherine Dolf explains in this weekâ€™s JAMA Report.

MANY ELDERLY NURSING HOMES RESIDENTS ARE FAMILIAR WITH HOSPITAL EMERGENCY DEPARTMENTS ESPECIALLY DURING THE WINTER MONTHS.Â OUTBREAKS OF THE NOROVIRUS ARE OFTEN THE REASON. THIS INFECTION CAN CAUSE VOMITING, DIARRHEA AND DEHYDRATION.

â€œIn a setting of nursing home where individuals live in close quarters, once one case begins it can become very easy to spread from person to person.â€

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Mr. Trivedi walking outside, graphic of map including states involved in study

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TARAK (Tar-ECK)TRIVEDI (Trah-Veh-DEE), A FOURTH YEAR MEDICAL STUDENT AT THE UNIVERSITY OF CHICAGO PRITZKER SCHOOL OF MEDICINE AND CO-AUTHORS EXAMINED 308 NURSING HOMES IN WISCONSIN, PENNSYLVANIA AND OREGON. ALL OF THESE HOMES EXPERIENCED AT LEAST ONE NOROVIRUS OUTBREAK BETWEEN JANUARY 2009 AND DECEMBER OF 2010.

â€œWhen we looked at nursing homes that had higher number of nurse hours per patient per day we didnâ€™t see these increased deaths during norovirus outbreaks. However, we didnâ€™t see the same association with hospitalizations.â€

INCREASED RATES OF BOTH HOSPITALIZATON AND DEATH WERE CONCENTRATED IN THE FIRST AND SECOND WEEKS OF THE OUTBREAKS, SUGGESTING THAT IDENTIFYING THE VIRUS EARLY IS IMPORTANT. FOR HEALTH CARE WORKERS, THOROUGH HAND WASHING WITH SOAP AND WATER IS RECOMMENDED AFTER PATIENT CONTACT. THIS HELPS REDUCE THE SPREAD OF INFECTION.

â€œFor health care workers who become infected with norovirus we recommend that they stay home from work and not participate in patient care for at least 48 hours until after theyâ€™ve actually recovered from their illness.â€

NURSING HOME RESIDENTS OFTEN HAVE OTHER UNDERLYING HEALTH ISSUES. RESEARCHERS SAY IT IS DIFFICULT TO ASSESS WHETHER THE OUTBREAK IS ACTUALLY CAUSING DEATH OR HOSPITALIZATION OR WHETHER IT IS HAPPENING SIMULTANEOUSLY DURING ANOTHER ILLNESS. CATHERINE DOLF, THE JAMA REPORT.

TAG:REASEARCHERS SAY BECAUSE DIAGNOSTIC TESTING OF SPORADIC ILLNESS IS LACKING, OUTBREAKS MAY PROVIDE THE BEST OPPORTUNITIES FOR IDENTIFYING THE ASSOCIATION BETWEEN NOROVIRUS AND DEATHS.

CHICAGO – In a study that included more than 300 Medicare-certified nursing homes, rates of hospitalization and death were substantially increased during outbreaks of norovirus gastroenteritis vs. non-outbreak periods, according to a study appearing in the October 24/31 issue of JAMA. The study is being published early online to coincide with its presentation at the ID (infectious disease) Week meeting.

“In the United States, nursing homes annually provide care to approximately 3.3 million residents’ and 22 percent of all deaths occur in these settings. Gastroenteritis outbreaks are common in nursing homes in high-income countries. Annually, more than 1,000 outbreaks of acute gastroenteritis are reported by nursing homes to U.S. public health agencies, and this likely represents only a fraction of the actual number due to underreporting. Although nearly half of all reported nursing home gastroenteritis outbreaks are never etiologically [the cause] confirmed because of challenges in performing diagnostic testing, norovirus is implicated in 86 percent of etiologically confirmed outbreaks,” according to background information in the article. Because hospitalizations and deaths are common among the vulnerable, elderly population in nursing homes, it is difficult to ascertain if there is actually a greater number of these events during norovirus outbreaks.

Tarak K. Trivedi, B.S., a 4th year medical student at the University of Chicago Pritzker School of Medicine, and colleagues conducted a study to assess the association between norovirus outbreaks and excess all-cause hospitalization and mortality in nursing homes. The study included 308 Medicare-certified nursing homes in Oregon, Wisconsin, and Pennsylvania that reported at least 1 confirmed or suspected norovirus outbreak to the Centers for Disease Control and Prevention’s National Outbreak Reporting System (NORS), January 2009 to December 2010. Deaths and hospitalizations occurring among residents of these nursing homes were identified through the Medicare Minimum Data Set (MDS). Rates of all-cause hospitalization and mortality during outbreak periods were compared with rates during non-outbreak periods, after adjusting for seasonality.

The nursing homes in the study reported a total of 407 norovirus outbreaks. The median (midpoint) duration of outbreaks was 13 days. Hospitalizations and deaths were reported in 119 (29 percent) and 30 (7 percent) outbreaks, respectively. A total of 67,730 hospitalizations and 26,055 deaths were reported in the nursing home cohort during follow-up. Nursing homes experienced 2,533 hospitalizations (124.0/home-year) and 1,097 deaths (53.7/ home-year) during outbreak periods compared with 65,197 hospitalizations (109.5/home-year) and 24,958 deaths (41.9/home-year) during non-outbreak periods. After adjusting for seasonality by month, the rates of hospitalization and death were significantly elevated during outbreak periods.

The increase in hospitalizations was concentrated in the initial week and the subsequent week, and the increased mortality rate was concentrated in the initial week, relative to outbreak onset. In subsequent weeks, the rates of hospitalizations and deaths returned to the levels observed in non-outbreak periods.

The researchers found that nursing homes with lower daily RN hours per resident had a significantly increased rate of mortality during norovirus outbreaks compared with baseline, while no increased risk was observed in homes with higher daily RN hours per resident. The increase in hospitalization rates did not show a similar pattern.

“In conclusion, we detected a consistently increased risk of hospitalization and death from all causes during norovirus outbreaks among residents in nursing homes from 3 U.S. states. As a next step, research should be directed to determine if this increase is directly attributable to norovirus infection and subsequent disease resulting from gastroenteritis. Additionally, more detailed information is necessary to understand the specific contributory causes and comorbidities of norovirus-associated deaths. Given the lack of diagnostic testing in sporadic illness, outbreaks may provide the best opportunities for identifying such associations between norovirus disease and deaths,” the authors write.

“At present, strategies for averting these severe outcomes include general treatment for dehydration and infection control to prevent and control outbreaks. More targeted interventions would be welcome and in light of recent progress with a norovirus vaccine, these results highlight a setting and population that may benefit if efficacy and safety of immunization can be demonstrated.”

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